Redefining Soft Tissue Sarcoma Imaging: The Expanding Role of Positron Emission Tomography/Computed Tomography: A...

Soft tissue sarcomas (STSs) are a heterogeneous group of mesenchymal malignancies with diverse biological behavior, posing significant challenges in tumor grading, prognostic stratification, and early treatment response assessment. While magnetic resonance imaging (MRI) remains the standard modality for local tumor evaluation, its ability to characterize tumor biology and predict clinical outcomes is limited. Advanced imaging, particularly positron emission tomography/computed tomography (PET/CT), plays a critical role in improving disease characterization and supporting personalized patient management.

This narrative review summarizes the role of PET/CT in STS, focusing on established and emerging radiotracers, quantitative PET metrics, and multiparametric imaging approaches, along with their clinical applications.

¹⁸ F-fluorodeoxyglucose (FDG) PET/CT remains the cornerstone of functional imaging in STS, with uptake correlating with tumor grade, aggressiveness, and prognosis. Quantitative parameters such as standardized uptake values, metabolic tumor volume, and total lesion glycolysis provide additional prognostic and predictive information. Non-FDG tracers targeting proliferation, amino acid transport, perfusion, and hypoxia offer complementary insights into tumor biology. Multiparametric PET imaging improves assessment of intratumoral heterogeneity and supports biopsy guidance, radiotherapy planning, and early treatment response evaluation. Emerging approaches, including PET/MRI, radiomics, and artificial intelligence, show promise for improving tumor characterization and predictive modeling; however, these techniques remain largely investigational and require further validation before routine clinical implementation.

PET/CT is a key modality in STS, enabling comprehensive assessment of tumor biology and supporting personalized management. Integration of quantitative metrics, novel radiotracers, and advanced analytical techniques is expected to improve diagnostic accuracy, prognostication, and treatment planning. Further large-scale studies are required to standardize methodologies and confirm clinical impact.